By Kerry Young, CQ Roll Call

February 4, 2015 - With almost 10 million people already slated to get insurance through federal and state marketplaces, Obama administration officials urged Americans who have not yet arranged their medical coverage for 2015 to do so ahead of a Feb. 15 deadline for health law enrollment.

"There is still time to sign up but the clock is ticking," Health and Human Services (HHS) Secretary Sylvia Mathews Burwell said on a recent call with reporters.

Earlier in the day, Burwell told the Senate Finance Committee that almost 7.5 million consumers had selected a plan or were automatically enrolled through the federal exchange healthcare.gov, while another 2.4 million had come into the system through state exchanges.

Burwell had some weeks back set the bar low for enrollment expectations, saying her goal was that at least 9.1 million people would enroll and pay their premiums early this year. That includes data from states that run their own enrollment websites.

The 7.5 million people who have signed up through the federal marketplace alone is up from a total of almost 7.3 million through the week of Jan. 23. HHS officials release a weekly snapshot of enrollment through healthcare.gov, which enrolls people in 37 states.

Among the regions with the greatest activity in recent weeks on the federal marketplace have been the greater Miami-Fort Lauderdale-West Palm Beach area of Florida, with more than 630,000 plans selected, and metro Atlanta, with almost 300,000, HHS said in a recent statement. About 87 percent of the people who have signed up so far through the healthcare.gov site have qualified for financial assistance, Burwell said.

February 5, 2015 -- The Tennessee legislature's recent early defeat of GOP Gov. Bill Haslam's plan to expand Medicaid to 280,000 residents may provide ammunition to opponents of expansion in states such as North Carolina, Florida, and Utah.

Haslam had called a special session devoted to expanding Medicaid that started early last week. The plan died in the state Senate Health and Welfare Committee, which voted it down by a 7–4 tally after one undecided lawmaker and one lawmaker who had planned to support it voted no.

Some legislators last week predicted the plan would pass that committee but die in one of the House committees also slated to consider it. Several members of the Insurance and Banking Committee opposed it. House Speaker Beth Harwell, a Republican, also expressed doubts about passage in the full House.

The quick loss means chances of reviving the issue this year are slim.

"There are hundreds of thousands of Tennesseans who need health care, who could get that in a way that doesn't cost the state anything," Haslam said after the vote. The federal government will pick up all of the costs of the people who qualify under expanded eligibility guidelines through 2016 before phasing down down its share to 90 percent of costs starting in 2020 under the health care law (PL 111-148, PL 111-152).

The image of a popular governor who was just re-elected losing on the issue that he singled out for his first-ever special session may cause other GOP governors or legislators to hesitate pushing for expansion. North Carolina Gov. Pat McCrory, who told President Barack Obama earlier this year that he is open to expansion, said in a speech to legislators this week that any Medicaid plan "must require personal and financial responsibility for those who would be covered."

In Florida, Gov. Rick Scott had endorsed the idea in previous years but never pushed for it in the face of resistance from legislators. Other states weighing expansions include Utah, Wyoming, Montana, and Idaho.

Americans for Prosperity, a conservative advocacy group, and other conservative critics such as the Beacon Center of Tennessee actively worked against expansion. Americans for Prosperity also campaigned against expansion in states such as Virginia, where Democratic Gov. Terry McAuliffe has been unable to persuade legislators to back the idea of covering more low-income people. In Tennessee, opponents of expansion wearing red T-shirts swarmed around the state capitol.

Americans for Prosperity did not respond to a request for an interview.

Some legislators demanded that the federal government and the state government sign an agreement before the legislature considers it. Others said they thought that the program would be too expensive and that ultimately, the state would have to pick up some costs. The special session opened with a prayer from a conservative critic of the plan, June Griffin, who said, "Oh, Lord, save Tennessee for Jesus' sake, and I pray that your will would be done that you would be our coverage, that we would not be forced into these edicts from Washington, D.C."

Hospitals and other medical providers are major advocates for providing coverage to more people, but the testimony of hospital officials did not sway Tennessee legislators.

The Tennessee debate "reveals how political this is rather than just based on policy," said Diane Rowland, executive director of the nonpartisan Kaiser Commission on Medicaid and the Uninsured, who said that the outcome "could affect other states." 

"If you've got deep rooted ideological viewpoints it'll be hard to overcome them with facts," she added.

Three-Way Fight

After the Supreme Court in June 2012 gave states more power to reject expansion, some health policy experts thought that the biggest challenges would be in creating agreements between governors and the Centers for Medicare and Medicaid Services (CMS). But the fight that some state legislatures are posing shows that a Medicaid expansion framework is truly a three-way negotiation.

"Many of the legislatures have a lot of reservations so it just shows you what an uphill climb it can be in some of these states," said Rowland.

However, Rowland added that state officials also are hearing of positive experiences and economic benefits from expansion. So far, 28 states and the District of Columbia have broadened eligibility for the program for the low-income. Ten of those are led by Republican governors.

One of those was in Indiana, where Gov. Mike Pence recently got approval from CMS to waive many rules as part of the expansion. One Tennessee official has said that the timing of the Indiana approval was not helpful, because legislators were able to see that Pence had gotten more concessions from federal officials than Haslam had. 

February 6, 2015 -- Arkansas GOP Gov. Asa Hutchinson is expected to sign legislation next week reauthorizing the state's novel Medicaid expansion program for another year.

The bill renewing and funding the expansion, which is provided to beneficiaries through private plans in the insurance marketplace created under the health law, is part of a two-bill package that the legislature is considering. The funding bill that allowed the program to continue cleared the legislature for Hutchinson's signature last week, while a separate measure creating a task force that will recommend further changes in the future is expected to pass the Senate next week and move on to Hutchinson's desk.

"The expectation is that early next week both will be signed," said spokesman J.R. Davis.

Earlier this year, some observers wondered whether Hutchinson would call for a quick end to the program or whether the legislature would try to kill it this year. The program must be reauthorized every year by a three-fourths vote in each chamber, so the legislature will debate the issue again next year.

If the program were to end, about 213,000 people would be affected.

However, Hutchinson said last month that the program should continue for another two years while a new task force meets to come up with recommendations for additional revisions.

The Arkansas framework, known as the "private option," was a model for several other states led by Republican governors that used Medicaid dollars to buy private plans for beneficiaries in the marketplace.

The House gave the funding reauthorization final approval by a 82-16 vote. The other measure has passed both chambers but because the House made minor changes, the Senate must concur and clear it.  

The governor said when the House approved both measures late last week that the vote "was a bipartisan effort and represents the right step forward as we seek ways to best reform Medicaid in Arkansas. I am grateful for the confidence that the legislature has placed in the task force and the opportunity it represents to guide the future of health care reform in Arkansas."

Twenty-eight states and the District of Columbia have agreed to expand Medicaid under the health care law since the U.S. Supreme Court gave states in 2012 more power to reject expansion. Ten of the states that broadened eligibility to more people were led by Republican governors

February 2, 2014 -- Medicaid and the Children's Health Insurance Program (CHIP) grew by about 17.5 percent from mid-2013 to November 2014, according to an updated enrollment report that the Centers for Medicare and Medicaid Services (CMS) released last week.

Children in Medicaid and families in CHIP comprised about 54 percent of the population in November.

States that expanded Medicaid eligibility for people with income of up to 138 percent of poverty grew significantly more than those that did not, but as in previous monthly reports, both types of states tended to see a net increase in enrollment. States that had broadened eligibility grew by 25.5 percent, while those that did not grew by about 7 percent through November.

The number of people in Medicaid or CHIP grew by more than 10.1 million people over the course of a little more than a year.

The change from October to November 2014 was modest but steady–about 444,324 people, or a 0.65 percent increase. That mirrored a 0.62 increase from September 2014 to October 2014, according to recent updated figures.

In November, nearly 69 million individuals were enrolled in Medicaid and CHIP. 

Medicaid monthly enrollment reports compare a three-month average from July to September 2013, before the first marketplace open enrollment period started, to the months after that. The reason why CMS officials use a three-month average is to mitigate the effect of any fluctuations in the data.

The monthly data give an indication of how much Medicaid is growing. The number of people getting coverage is rising in part because some states expanded Medicaid eligibility in 2014 and in part because people who qualify for the programs are seeing more publicity about the benefits.

"These numbers are encouraging–not because of the continued growth–but because they reflect the millions of lives changed by the Affordable Care Act," said Vikki Wachino, Acting Director of the Center for Medicaid and CHIP Service, in a blog post. Wachino assumed the post last week after the previous director, Cindy Mann, left the administration, according to an administration official.

"We are encouraged by interest from governors from all across the country who understand both the economic benefits of Medicaid expansion and the health and financial security it brings to many individuals," Wachino wrote.

February 2, 2014 -- President Barack Obama's budget would strip away about $399 billion in federal health costs over a decade, with the bulk of the proposed savings coming from reducing Medicare payments for drugs and services for people recovering from serious illness or injuries.

Certain high-earners enrolled in Medicare, the federal health program for the elderly and disabled, also would pay more out of pocket for drug and outpatient services.
The White House would expand and overhaul certain other programs for the decade ending in fiscal 2025.

Among these new expenses is a $44 billion tab for what's described as an overhaul of Medicare payments to doctors to "promote participation in high-quality and efficient health care delivery systems."

The White House also wants to eliminate a 190-day lifetime Medicare limit on use of inpatient psychiatric center services, with an estimated ten-year cost of $5 billion. And the administration proposed to require full coverage of preventive health and tobacco cessation services for adults in traditional Medicaid, the health program for the poor, at a cost of $754 million.

In many cases, the fiscal 2016 budget request recycled past proposals. Some $66.4 billion over a decade would come from raising income-related premiums for Medicare Part B services, which include routine medical care, and the Part D prescription drug program. In last year's budget request, similar changes to Part D and Part B premiums were estimated to generate about $52.8 billion.

This year's request also projects $102 billion in savings over a decade from blocking payment increases for certain kinds of centers and hospitals that help people recover after serious illnesses and injuries. The estimate of savings was about $98 billion in the fiscal 2015 request.

The new budget plan estimates savings of $116 billion from aligning Medicare drug payment policies with less generous ones used for Medicaid. That was little changed from a $117 billion estimate cited in the fiscal 2015 request.

The latest White House budget also calls for cuts to so-called critical-access hospitals so that facilities are paid at 100 percent of "reasonable costs" for savings of $1.73 billion. 

Hospitals already have signaled their displeasure.

"While we welcome reform initiatives that strengthen hospital's progress in transforming health care delivery, policymakers must also understand that further hospital cuts undermine our ability to innovate and invest in key structural health care changes that are driving the health care spending slowdown and historic low growth in hospital prices," said Chip Kahn, president of the Federation of American Hospitals in a recent statement. "Cuts to hospital Medicare payments will destabilize this dynamic, and impede important transformations that are improving the efficiency and quality of our health care delivery system."

The American Hospital Association had registered objections last month to such proposals, asking Obama in a January letter not to repeat cuts such as the haircut for critical-access hospital payment rates.

February 4, 2015 -- A GOP plan to replace the 2010 health care law would tax workers' medical coverage if it was valued at more than $12,000 for an individual or $30,000 for a family.  

The blueprint, released last week, is backed by Senate Finance Chairman Orrin G. Hatch, R-Utah; Finance member Richard M. Burr, R-N.C., and House Energy and Commerce Chairman Fred Upton, R-Mich.

The plan mirrors a proposal Hatch and Burr released last year and faces an almost certain veto should it reach President Barack Obama's desk. Though Republicans don't plan on introducing it as a bill in the immediate future and it lacks critical details such as a cost estimate, the plan offers details about how Republicans could replace the health care overhaul (PL 111-148, PL 111-152) if a GOP candidate captures the White House in 2016.

More immediately, it could help frame debate this summer if the Supreme Court strikes down subsidies for private insurance in states that rely on the health law's federal marketplace for enrollment. Plaintiffs in a case to be argued March 4 contend Congress only intended federal subsidies for insurance to be available in states that run their own enrollment websites, which could result in about 13 million Americans losing subsidies in 2016, according to the nonpartisan Kaiser Family Foundation.

The added taxes on workers' insurance would raise revenue and help hold down rising medical costs, and it and is one of the only changes from the GOP replacement plan put forward last year by Hatch, Burr and then-Sen. Tom Coburn, R-Okla. The previous plan also capped the tax exclusion for workers' coverage, but did so through a formula that some criticized as too complicated. 

This year's version includes more robust medical malpractice limits, according to Republican aides. GOP lawmakers want to cap pain-and-suffering damages in lawsuits and attorneys' fees, as well as encourage states to adopt additional changes.

A third change from last year is that the group included a long-held GOP principle that consumers should be able to buy insurance offered in different states. 
Aides do not know how many people would have insurance under the proposal or how much it would cost.

Republicans would repeal most of the 2010 law, including mandates that most people obtain coverage and that most larger employers offer insurance to workers or face fines.

The proposal would wipe out the law's ban on annual coverage limits by insurers, requirements that insurance cover certain medical services and a rule that patients can get preventive care without having to pay out-of-pocket costs. And it would significantly cut spending on coverage for low-income people by repealing the law's expansion of Medicaid, which opens up the program to those with incomes of up to 138 percent of the federal poverty level in states that choose to expand coverage. The proposal would cap Medicaid spending. 

But the plan would retain the health care overhaul's Medicare cuts for providers such as hospitals.

The Republican trio of lawmakers also would keep a ban on lifetime limits on insurance coverage and continue to allow adult children to stay on their parents' insurance plans until age 26, unless states decide to opt out.

Coverage Denials

The plan would replace the health law's ban on higher charges or coverage denials for people with pre-existing medical conditions with narrower protections. Under the GOP plan, insurers could charge higher prices to cover preexisting conditions if a consumer is uninsured for more than two months or unless the person previously had coverage for less than 18 months.

The addition of Upton to the plan's supporters signals that Republicans in both chambers hope to coordinate their message on health care. Upton said Republicans are "presenting these ideas to the American people and offering a path to the health coverage and care they want."

The Republicans are willing to further tweak their plan.

"This plan is achievable, and above all, fiscally sustainable," said Hatch. "And unlike the passage of Obamacare, which was done in secret, we welcome input from the American people."